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Background: Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends. Methods: Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix–adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index. Results: The median annual number of Medicare admissions was 5214 (range, 408–18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94–1.02]; P =0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99–1.02]; P =0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals. Conclusions: Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes.

Background: Recent reports on challenges in resuscitation care at hospitals severely affected by the novel coronavirus disease 2019 (COVID-19) pandemic raise questions about how the pandemic affected outcomes for in-hospital cardiac arrest throughout the United States. Methods: Within Get With The Guidelines–Resuscitation, we conducted a retrospective cohort study to compare in-hospital cardiac arrest survival during the presurge (January 1–February 29), surge (March 1–May 15) and immediate postsurge (May 16–June 30) periods in 2020 compared to 2015 to 2019. Monthly COVID-19 mortality rates for each hospital’s county were categorized, per 1 000 000 residents, as low (0–10), moderate (11–50), high (51–100), or very high (>100). Using hierarchical regression models, we compared rates of survival to discharge in 2020 versus 2015 to 2019 for each period. Results: Of 61 586 in-hospital cardiac arrests, 21 208 (4309 in 2020), 26 459 (5949 in 2020), and 13 919 (2686 in 2020) occurred in the presurge, surge, and postsurge periods, respectively. During the presurge period, 24.2% survived to discharge in 2020 versus 24.7% in 2015 to 2019 (adjusted odds ratio, 1.12 [95% CI, 1.02–1.22]). In contrast, during the surge period, 19.6% survived to discharge in 2020 versus 26.0% in 2015 to 2019 (adjusted odds ratio, 0.81 [0.75–0.88]). Lower survival was most pronounced in communities with high (28% lower survival) and very high (42% lower survival) monthly COVID-19 mortality rates (interaction P P P =0.004) during the surge period. Survival was lower even when patients with confirmed/suspected COVID-19 infection were excluded from analyses. During the postsurge period, survival rates were similar in 2020 versus 2015 to 2019 (22.3% versus 25.8%; adjusted odds ratio, 0.93 [0.83–1.04]), including communities with high COVID-19 mortality (interaction P =0.16). Conclusions: Early during the pandemic, rates of survival to discharge for IHCA decreased, even among patients without COVID-19 infection, highlighting the early impact of the COVID-19 pandemic on in-hospital resuscitation.

Background Patients with sudden cardiac arrest occurring in the acute phase of myocardial infarction (MI-SCA) are believed to be at similar risk of death after revascularization compared with MI patients without SCA (MI-no SCA). Among patients with anterior MI, we examined whether those with MI-SCA were at greater risk of all-cause mortality or sudden cardiac death (SCD) than MI-no SCA patients. Methods The Home Automated External Defibrillator Trial enrolled patients with anterior MI who had not received or were candidates for an implantable cardioverter defibrillator (ICD). Our cohort included patients with a reported SCA event, in the acute phase of an MI, prior to HAT trial enrollment. Cox proportional hazards models examined the adjusted association between MI-SCA versus MI-no SCA patients and all-cause mortality and sudden cardiac death (SCD). We also determined whether the relationship between prior SCA and outcomes changed with subsequent events (syncope, revascularization, and recurrent MI) during follow-up. Results Of 6849 patients, 650 (9.5%) had MI-SCA before trial enrollment. Approximately 48% of patients had the MI-SCA event ≤ 1 year prior to enrollment; 71% of SCA events were in-hospital. MI-SCA patients were younger, more frequently white, and had higher rates of prior PCI versus MI-no SCA patients. There were no differences in adjusted all-cause mortality (hazard ratio [HR 0.95; 95% CI 0.65-1.38]) or SCD (HR 1.12; 95% CI 0.68-1.83) for MI-SCA vs. MI-no SCA. After ICD implantation, MI-SCA patients experienced higher all-cause mortality risk (HR 5.01, 95% CI 1.05-23.79) versus MI-no SCA patients; there was no mortality difference between MI-SCA and MI-no SCA patients without ICD implantation (HR 0.89, 95% CI 0.60- 1.31), [interaction p=0.035]. Conclusions Patients with MI-SCA had similar adjusted risk of all-cause mortality and SCD compared with MI-no SCA. After ICD implantation, MI-SCA patients had higher mortality compared with MI-no SCA patients.

Highlights • COVID-19 pandemic has changed the risk-benefit balance for cardiopulmonary resuscitation [CPR]. • Amongst many aerosol producing procedures performed on patients, CPR is a highly aerosol-generating procedure. • Available literature is inadequate to direct clinicians towards keeping low or high threshold for performing CPR in COVID-19 patient.

Cluster randomized trials (CRTs) refer to experiments with randomization carried out at the cluster or the group level. While numerous statistical methods have been developed for the design and analysis of CRTs, most of the existing methods focused on testing the overall treatment effect across the population characteristics, with few discussions on the differential treatment effect among subpopulations. In addition, the sample size and power requirements for detecting differential treatment effect in CRTs remain unclear, but are helpful for studies planned with such an objective. In this article, we develop a new sample size formula for detecting treatment effect heterogeneity in two-level CRTs for continuous outcomes, continuous or binary covariates measured at cluster or individual level. We also investigate the roles of two intraclass correlation coefficients (ICCs): the adjusted ICC for the outcome of interest and the marginal ICC for the covariate of interest. We further derive a closed-form design effect formula to facilitate the application of the proposed method, and provide extensions to accommodate multiple covariates. Extensive simulations are carried out to validate the proposed formula in finite samples. We find that the empirical power agrees well with the prediction across a range of parameter constellations, when data are analyzed by a linear mixed effects model with a treatment-by-covariate interaction. Finally, we use data from the HF-ACTION study to illustrate the proposed sample size procedure for detecting heterogeneous treatment effects.

BACKGROUND: While survival after in-hospital cardiac arrest (IHCA) has improved in recent years, it remains unknown whether this trend primarily applies to younger IHCA victims. The aim of this study was to assess trends in survival to hospital discharge after adult IHCA across age groups from 2000 to 2016.METHODS: This is an observational study of IHCA patients included in the Get With The Guidelines®-Resuscitation registry between 2000 and 2016. The primary outcome was survival to hospital discharge. Patients were stratified into five age groups: RESULTS: A total of 234,767 IHCA patients were included. The absolute increase in survival per calendar year was 0.8% (95% CI 0.7-1.0%, p CONCLUSIONS: For patients with IHCA, rates of survival to discharge have improved significantly from 2000 to 2016 across all age groups.

Background Studies have reported lower survival for in-hospital cardiac arrest (IHCA) during the initial COVID-19 surge. Whether the pandemic reduced IHCA survival during subsequent surges and in areas with lower COVID-19 rates is unknown. Methods Within Get-With-The-Guidelines®-Resuscitation, we identified 22,899 and 79,736 IHCAs during March to December in 2020 and 2015-2019, respectively. Using hierarchical regression, we compared risk-adjusted rates of survival to discharge in 2020 vs. 2015-19 during five COVID-19 periods: Surge 1 (March to mid-May), post-Surge 1 (mid-May to June), Surge 2 (July to mid-August), post-Surge 2 (mid-August to mid-October), and Surge 3 (mid-October to December). Monthly COVID-19 mortality rates for each hospital’s county were categorized, per 1,000,000 residents, as very low (0-10), low (11-50), moderate (51-100), or high (>100). Results During each COVID-19 surge period in 2020, rates of survival to discharge for IHCA were lower, as compared with the same period in 2015-2019: Surge 1: adjusted OR: 0.81 (0.75-0.88); Surge 2: adjusted OR: 0.88 (0.79-0.97), Surge 3: adjusted OR: 0.79 (0.73-0.86). Lower survival was most pronounced at hospitals located in counties with moderate to high monthly COVID-19 mortality rates. In contrast, during the two post-surge periods, survival rates were similar in 2020 vs. 2015-2019: post-Surge 1: adjusted OR 0.93 (0.83-1.04) and post-Surge 2: adjusted OR 0.94 (0.86-1.03), even at hospitals with the highest county-level COVID-19 mortality rates. Conclusions During the three COVID-19 surges in the U.S. during 2020, rates of survival to discharge for IHCA dropped substantially, especially in communities with moderate to high COVID-19 mortality rates.

Background and objectives Patients on maintenance dialysis with in-hospital cardiac arrest have been reported to have worse outcomes relative to those not on dialysis; however, it is unknown if poor outcomes are related to the quality of resuscitation. Using the Get With The Guidelines-Resuscitation (GWTG-R) registry, we examined processes of care and outcomes of in-hospital cardiac arrest for patients on maintenance dialysis compared with nondialysis patients. Design, setting, participants, & measurements We used GWTG-R data linked to Centers for Medicare and Medicaid data to identify patients with ESKD receiving maintenance dialysis from 2000 to 2012. We then case-matched adult patients on maintenance dialysis to nondialysis patients in a 1:3 ratio on the basis of age, sex, race, hospital, and year of arrest. Logistic regression models with generalized estimating equations were used to assess the association of in-hospital cardiac arrest and outcomes by dialysis status. Results After matching, there were a total of 31,144 GWTG-R patients from 372 sites, of which 8498 (27%) were on maintenance dialysis. Patients on maintenance dialysis were less likely to have a shockable initial rhythm (20% versus 21%) and less likely to be within the intensive care unit at the time of arrest (46% versus 47%) compared with nondialysis patients; they also had lower composite scores for resuscitation quality (89% versus 90%) and were less likely to have defibrillation within 2 minutes (54% versus 58%). After adjustment, patients on maintenance dialysis had similar adjusted odds of survival to discharge (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 0.97 to 1.13), better acute survival (OR, 1.33; 95% CI, 1.26 to 1.40), and were more likely to have favorable neurologic status (OR, 1.12; 95% CI, 1.04 to 1.22) compared with nondialysis patients. Conclusions Although there appears to be opportunities to improve the quality of in-hospital cardiac arrest care for among those on maintenance dialysis, survival to discharge was similar for these patients compared with nondialysis patients.

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

Background: The general public is unfamiliar with the concept of medical drones delivering life-saving technologies. Our research sought to define stakeholder attitudes towards development of drone-based emergency care for out-of-hospital cardiac arrest. Methods: Using qualitative methodology, we explored key stakeholder attitudes about using a drone to deliver automated external defibrillators (AED), challenges and facilitators to early establishment of a drone AED network, implementation considerations, and factors related to long-term sustainability. We identified 22 key individuals as potential respondents based on professional position; 16 respondents participated in data collection. Research participants included leaders in government, healthcare, emergency services, business, community, and the aviation industry (regulation and drone operation). Interview data were recorded and transcribed; data were analyzed using NVivo. A coding schema was developed based on constructs identified in previous literature and inductive consideration of this study’s data, including both thematic and descriptive coding. Results: We found broad support for a drone-delivered AED network. Such a network was perceived as valuable for reduced response times and for enhanced access to hard-to-reach areas. Identified challenges included operationalizing an autonomous drone AED network, privacy and safety concerns, current legal and regulatory requirements, financial liabilities, public buy-in and concern for public actually using an AED, and the need for research on treatment and cost- effectiveness of a drone network. Facilitators of development for a drone AED network included solidifying key partnerships (including integration into current EMS or fire services), identifying viable funding from private and public entities, and learning from existing drone models (e.g. commercial package or medical supply delivery). Conclusion: This study found general and conceptual support for the development of a drone network for AED delivery across key informants from an array of related fields. Such information should be considered in developing a regional drone AED network.

Background: Drones have great potential to speed the delivery of AEDs in the critical first few minutes of OHCA. However, it is unclear whether bystanders can balance high-quality cardiopulmonary resuscitation (CPR) with AED deployment. The 2015 AHA CPR guidelines recommend a chest compression (cc) rate of 100-120/minute, cc depth of 50-60mm, and cc fraction of >60%. Method: We performed mock cardiac arrest simulations using bystander volunteers, including simulated 911 call, telephone-assisted dispatcher CPR instructions, bystander CPR, drone-delivered AED, and AED application. CPR performance was recorded by a Laerdal Resusci Anne Quality Feedback System and compared between two groups of participants: recent CPR training (2 years) or no CPR training. Prior data had shown CPR skill degradation after 2 years. Chi-squared tests compared demographics; T-tests compared age and CPR performance data. Results: Between 9/2019-3/2020, 5 simulations were conducted with 51 participants. The mean age was 39.7 years, 56.9% were female, and 78.4% had a college or graduate degree. Racial/ethnic makeup consisted of 64.7% White, 15.7% African-American, 15.7% Asian, and 11.8% Hispanic. 41.2% had recent CPR training (n=21); 58.8% had remote CPR training (n=19) or no CPR training (n=11). There were no differences in demographics by CPR training groups. Participants with recent CPR training had shorter time from CPR initiation to AED shock delivery (3:45 vs. 4:14 [min:sec], p=0.01) and a trend toward higher percent of time with cc depth (77.4% vs 50.4%, p=0.11) and higher cc fraction (46.8% vs 42.9 %, p=0.12). There were no differences for percent of time with cc rate or CPR recoil. Conclusion: Overall, CPR quality was low regardless of prior CPR training status. Those recently trained had shorter resuscitation time and appeared to have better CPR performance. Realization of a drone AED networks may require novel CPR programs focused on high-quality CPR.

Introduction: Bystander CPR (B-CPR) and defibrillation for sudden cardiac arrest (SCA) vary by gender with females being less likely to receive these interventions. Despite known differences by race and ethnicity, it is unknown whether gender disparities in B-CPR and defibrillation persist by neighborhood race and ethnicity. Objectives: We examined the likelihood of receiving B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition. We hypothesized that in public locations within Black neighborhoods, females will have a lower likelihood of receiving B-CPR compared to males. Methods: We conducted a retrospective cohort study using data from the US Cardiac Arrest Registry to Enhance Survival (CARES) registry. Neighborhoods were classified by census tract based on percent of Black or Hispanic residents using the threshold in the definition of “White flight” where Whites leave a neighborhood when it exceeds >30% of a minority population. We independently modeled the likelihood of receipt of B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition controlling for confounding variables. Results: From 2013-2018, CARES collected 350,722 US arrests; after excluding pediatric arrests, those witnessed by EMS, or those that occurred in a healthcare facility, 214,464 were included. Mean age was 64±16 and 65% were male; 39% received B-CPR, 9% received bystander defibrillation prior to 9-1-1 responders arrival, and 18% occurred in the public. In Black neighborhoods, females who had SCA in public locations were 22% less likely to receive B-CPR (OR: 0.78 (0.64-0.95), p=0.01) and 42% less likely to receive defibrillation (OR: 0.58 (0.45-0.74), p Conclusion: Females with public SCA have a decreased likelihood of receiving B-CPR and defibrillation, and these findings persist in Black and Hispanic neighborhoods. This has implications for strategies to reduce disparities around bystander response to SCA.

BACKGROUND: Undergoing percutaneous coronary intervention (PCI) is a risk factor for AKI development, but few studies have quantified racial differences in AKI incidence after this procedure. METHODS: We examined the association of self-reported race (Black, White, or other) and baseline eGFR with AKI incidence among patients who underwent PCI at Duke University Medical Center between January 1, 2003, and December 31, 2013. We defined AKI as a 0.3 mg/dl absolute increase in serum creatinine within 48 hours, or ≥1.5-fold relative elevation within 7 days post-PCI from the reference value ascertained within 30 days before PCI. RESULTS: Of 9422 patients in the analytic cohort (median age 63 years; 33% female; 75% White, 20% Black, 5% other race), 9% developed AKI overall (14% of Black, 8% of White, 10% of others). After adjustment for demographics, socioeconomic status, comorbidities, predisposing medications, PCI indication, periprocedural AKI prophylaxis, and PCI procedural characteristics, Black race was associated with increased odds for incident AKI compared with White race (odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.48 to 2.15). Compared with Whites, odds for incident AKI were not significantly higher in other patients (OR, 1.30; 95% CI, 0.93 to 1.83). Low baseline eGFR was associated with graded, higher odds of AKI incidence (P value for trend

Background Cardiac arrest is the leading cause of death among patients receiving hemodialysis. Despite guidelines recommending CPR training and AED presence in dialysis clinics, rates of CPR and AED use by dialysis staff are suboptimal. Given that racial disparities exist in bystander CPR administration in non-healthcare settings, we examined the relationship between patient race/ethnicity and staff-initiated CPR and AED application within dialysis clinics. Methods We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013 to 2017 and the Centers for Medicare & Medicaid Services dialysis facility database to identify outpatient dialysis clinic cardiac arrest events. Using multivariable logistic regression models, we examined relationships between patient race/ethnicity and dialysis staff-initiated CPR and AED application. Results We identified 1568 cardiac arrests occurring in 809 hemodialysis clinics. The racial/ethnic composition of patients was 31.3% white, 32.9% Black, 10.7% Hispanic/Latinx, 2.7% Asian, and 22.5% other/unknown. Overall, 88.0% of patients received CPR initiated by dialysis staff, but rates differed by race: 91% of white patients, 85% of black patients, and 77% of Asian patients (p = 0.005). After adjusting for differences in patient and clinic characteristics, black (OR = 0.41, 95% CI 0.25–0.68) and Asian patients (OR = 0.28, 95% CI 0.12–0.65) were significantly less likely than white patients to receive staff-initiated CPR. No significant difference between staff-initiated CPR rates among white, Hispanic/Latinx, and other/unknown patients was observed. An AED was applied by dialysis staff in 62% of patients. In adjusted models, there was no relationship between patient race/ethnicity and staff AED application. Conclusions Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff. Further understanding of practices in dialysis clinics and increased awareness of this disparity are necessary to improve resuscitation practices.

Background Women have higher utilization of “do not attempt resuscitation” ( DNAR ) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation ( ROSC ) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC , within 12 hours of ROSC , or within 72 hours of ROSC ) by sex and the association between sex and survival to discharge accounting for DNAR . All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI , 1.10–1.20]; P DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P CI , 0.99–1.02]; P =0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR . However, women had a higher rate of DNAR status early after resuscitation (

Large variations exist in the care processes and outcomes for patients who experience in-hospital cardiac arrest (IHCA). We examined if Get With The Guidelines-Resuscitation (GWTG-R) participation duration was associated with improved care processes.We calculated an overall process composite performance score for IHCA patients using five guideline-recommended process measures, calculating composite adherence among patients, and grouped at hospitals based on GWTG-R participation duration. Trend tests using logistic regression with generalized estimating equations examined the impact of participation duration on quality. Using multivariable regression models adjusting for patient factors, hospital factors, secular trends, and GWTG-R participation duration, we assessed the association between participation duration and process composite performance. We examined 149,551 patients from 447 hospitals (2000-2012). Over the study period we saw decreases in: median age of cardiac arrest (71 to 67 years), the proportion of whites (69.2% to 66.6%), and pulseless ventricular tachycardia/ventricular fibrillation frequency (32.3% to 17.3%). Hospitals were increasingly more likely to be in urban locations and have higher nurse-to-bed ratios. Guideline performance adherence improved with participation duration for several individual process measures and overall process composite performance: process composite score (P-value trend P.001), confirmation of endotracheal tube (P.001 trend), monitored/witnessed event (P.001 trend), time to first chest compressions ≤1 minute (P.001 trend), and time to vasopressor use ≤5 minutes (P-value trend = 0.0004). There was a decrease in adherence as duration of participation increased for time to defibrillation ≤2 minutes (P-value trend = 0.005). After adjusting for several factors including calendar time, GWTG-R participation duration was independently associated with improved process composite performance (OR 1.05 per year, 95% CI 1.03-1.07).GWTG-R participation duration was associated with a significant improvement in IHCA quality of care, yet significant opportunities remain to find ways to maximize quality of care in this high-risk patient group.

Background: Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown. Methods: We linked data from a national IHCA registry with Medicare files and identified 36 961 patients ≥65 years of age with an IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA caused by pulseless ventricular tachycardia or ventricular fibrillation were stratified by prompt (≤2 minutes) versus delayed (>2 minutes) defibrillation, whereas patients with IHCA caused by asystole or pulseless electric activity were stratified by prompt (≤5 minutes) versus delayed (>5 minutes) epinephrine treatment. The association between prompt treatment and long-term survival for each rhythm type was assessed with multivariable hierarchical modified Poisson regression models. Results: Of 8119 patients with an IHCA caused by ventricular tachycardia or ventricular fibrillation, the rate of 1-year survival was higher in those treated with prompt defibrillation than with delayed defibrillation (25.7% [1466 of 5714] versus 15.5% [373 of 2405]; adjusted relative risk [RR], 1.49; 95% confidence interval [CI] 1.32–1.69; P P P P =0.02), but this survival benefit was no longer present at 3 years (3.5% versus 2.9%; adjusted RR, 1.17; 95% CI, 0.95–1.45; P =0.15) and at 5 years (2.3% versus 1.9%; adjusted RR, 1.18; 95% CI, 0.88–1.58; P =0.27). Conclusions: Prompt defibrillation for IHCA caused by ventricular tachycardia or ventricular fibrillation was associated with higher rates of long-term survival throughout 5 years of follow-up, whereas prompt epinephrine treatment for asystole/pulseless electric activity was associated with greater survival at 1 year but not at 3 or 5 years. By quantifying the greater survival associated with timely defibrillation and epinephrine administration, these findings provide important insights into the durability of survival benefits for 2 process-of-care measures in current resuscitation guidelines.

Introduction: Survival from out-of-hospital cardiac arrest (OHCA) remains low and with major regional variation. This study explored differences in patients, care, and survival in patients with OHCA in North Carolina (NC), Washington State (WA), and Denmark. Methods: We identified a total of 17,277 adult patients with OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) registry and the Danish Cardiac Arrest Register of presumed cardiac cause from 2013-2014. Patients were categorized into three regions: two states in the United States (NC, 9.1 million inhabitants, WA, 7.5 million inhabitants) and the country of Denmark (5.8 million inhabitants). Outcomes of cardiopulmonary resuscitation (CPR) and defibrillation performed by either professional first responder or lay bystanders prior to emergency medical service (EMS) arrival, as well as overall survival. Data were analyzed using multivariable logistic regression analyses adjusted for age, sex, calendar year, location of arrest and witnessed status. Results: Patients in NC and WA were younger and had more racial variation compared to Denmark. Survival was 9.3% in NC, 14.5% in WA and 13.3% in Denmark. Using the Danish cohort as reference, the odds for bystander CPR and defibrillation in NC (CPR: OR 0.41, 95%CI 0.38-0.44; defibrillation: OR 0.30, 95%CI 0.23-0.38) and WA (CPR: OR 0.71, 95%CI 0.65-0.77; defibrillation: OR 0.41, 95%CI 0.31-0.53) were lower, respectively. CPR and defibrillation performed by either a bystander or a professional first responder prior to EMS arrival were higher in NC (CPR: OR 2.67, 95%CI 2.43-2.93; defibrillation: OR 2.72 95%CI 2.30-3.21), but not in WA (CPR: OR 1.01, 95%CI 0.92-1.11; defibrillation OR 0.73, 95%CI 0.58-0.90), respectively. Compared with Denmark, survival was lower in NC (OR 0.39, 95%CI 0.34-0.45) and WA (OR 0.83, 95%CI 0.72-0.95). Conclusion: Survival following OHCA was higher in Denmark and WA than in NC, and was associated with higher rates of bystander CPR and defibrillation. However, CPR and defibrillation prior to EMS arrival, mainly from professional first responders, was significantly higher in NC. A combination of both bystander and first responder interventions may be the optimal approach to improve outcomes of cardiac arrest.

AIM: We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state.METHODS: OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban RESULTS: Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival.CONCLUSIONS: During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

With recent regulatory changes that allow for commercial unmanned aerial vehicle (UAV)operations, there has been increasing interest in using UAVs, aka drones, for delivery of medical care, especially in rural areas. Previous work has focused on Automated External Defibrillators (AEDs)for people in possible cardiac arrest, but there are potentially many other emergency medical interventions that could be made more readily available through drones. One such use includes treatment for opioid overdoses, which could be significant given the current US opioid crisis. While drone delivery of blood has been established in Africa between medical professionals, there are no established applications of drones delivering emergency medical interventions for use by bystanders due to technical issues in the safe operation of drones in the air and in accessing and using the medical devices on the ground by laypersons. This paper examines how such a drone system should be designed in order to promote safe and effective operations for all stakeholders. This complex system design problem should be addressed at both local and global levels. At the local level, new theories and applications of human-technology interaction should be developed considering the need to promote safe and efficient human interaction between bystanders and drones delivering emergency medical interventions. Resulting models will need to consider how affordances can be designed into the technology given the use by untrained bystanders. Given that these emergency drones will need to be remotely supervised, the global aspect of this research should focus on the development of a drone supervision/dispatch capability, which will include interacting with the layperson who initiated the emergency call and determining how to integrate new network optimizations models so that dispatchers can understand when and where to dispatch drones and/or ambulances.

BACKGROUND: Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown.METHODS: We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS).RESULTS: Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms.CONCLUSIONS: Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.

Background The Institute of Medicine has called for actions to understand and target sex‐related differences in care and outcomes for out‐of‐hospital cardiac arrest patients. We assessed changes in bystander and first‐responder interventions and outcomes for males versus females after statewide efforts to improve cardiac arrest care. Methods and Results We identified out‐of‐hospital cardiac arrests from North Carolina (2010–2014) through the CARES (Cardiac Arrest Registry to Enhance Survival) registry. Outcomes for men versus women were examined through multivariable logistic regression analyses adjusted for (1) nonmodifiable factors (age, witnessed status, and initial heart rhythm) and (2) nonmodifiable plus modifiable factors (bystander cardiopulmonary resuscitation and defibrillation before emergency medical services), including interactions between sex and time (ie, year and year 2 ). Of 8100 patients, 38.1% were women. From 2010 to 2014, there was an increase in bystander cardiopulmonary resuscitation (men, 40.5%–50.6%; women, 35.3%–51.8%; P for each P =0.007; women, 8.5%–23.7%, P =0.004). From 2010 to 2014, the unadjusted predicted probability of favorable neurologic outcome was higher and increased more for men (men, from 6.5% [95% confidence interval (CI), 5.1–8.0] to 9.7% [95% CI, 8.1–11.3]; women, from 6.3% [95% CI, 4.4–8.3] to 7.4% [95% CI, 5.5–9.3%]); while adjusted for nonmodifiable factors, it was slightly higher but with a nonsignificant increase for women (from 9.2% [95% CI, 6.8–11.8] to 10.2% [95% CI, 8.0–12.5]; men, from 5.8% [95% CI, 4.6–7.0] to 8.4% [95% CI, 7.1–9.7]). Adding bystander cardiopulmonary resuscitation and defibrillation before EMS (modifiable factors) did not substantially change the results. Conclusions Bystander and first‐responder interventions increased for men and women, but outcomes improved significantly only for men. Additional strategies may be necessary to improve survival among female cardiac arrest patients.

Background Maternal mortality has risen in the United States in the twenty-first century, yet large cohort data of maternal cardiac arrest (MCA) are limited. Objective We sought to describe contemporary characteristics and outcomes of in-hospital MCA. Methods We queried the American Heart Association’s Get with the Guidelines Resuscitation voluntary registry from 2000 to 2016 to identify cases of maternal cardiac arrest. All index cardiac arrests occurring in women aged 18–50 with a patient illness category designated as obstetric or location of arrest occurring in a delivery suite were included. Institutional review deemed that this research was exempt from ethical approval. Results A total of 462 index events met criteria for MCA, with a mean age of 31 ± 7 years and a racial distribution of: 49.4% White, 35.3% Black and 15.3% Other/Unknown. While 32% had no pre-existing conditions or physiologic disorders, respiratory insufficiency (36.1%) and hypotension/hypoperfusion (33.3%) were the most common antecedent conditions. In most cases, the first documented pulseless rhythm was non-shockable; pulseless electrical activity (50.8%) or asystole (25.6%). Only 11.7% presented with a shockable rhythm; ventricular fibrillation (6.5%) or pulseless ventricular tachycardia (5.2%) while the initial pulseless rhythm was unknown in 11.9% of cases. Return of spontaneous circulation occurred in 73.6% but 68 (14.7%) had more than one arrest. The rate of survival to discharge was 40.7% overall; 37.3% with non-shockable rhythms, 33% with shockable rhythms and 64.3% with unknown presenting rhythms. Conclusions Maternal survival at hospital discharge in this cohort was less than 50%, lower than rates reported in other epidemiological datasets. More research is required in maternal resuscitation science and translational medicine to continue to improve outcomes and understand maternal mortality.

Based on our collective early career experiences, we will provide the key elements in a road map for a successful physician-scientist. Discussion includes the importance of mentoring, establishing successful collaboration, time management, work-life balance, and submitting a successful grant.

Despite the high incidence of in-hospital cardiac arrest (IHCA) in US hospitals, the prognosis and end-of-life decision-making patterns of a patient with a recurrent IHCA are unknown.Within Get-With-The-Guidelines-Resuscitation, we identified 192,250 patients from 711 hospitals with an IHCA from 2000 to 2015. Patients were categorized as having no recurrent IHCA (only 1 event), recurrent IHCA (≥2 IHCAs), and recurrent out-of-hospital cardiac arrest (OHCA), defined as an IHCA after an OHCA. Using multivariable hierarchical logistic regression, rates of survival to discharge and favorable neurological survival (mild or no disability) between the 3 groups were compared. Rates of de novo "do not attempt resuscitation" (DNAR) and withdrawal of care orders among successfully resuscitated patients were also evaluated.Overall, 165,446 (86.1%) had no recurrent IHCA, 23,643 (12.3%) had recurrent IHCA, and 3162 (1.6%) had recurrent OHCA. Compared with patients with no recurrent IHCA, patients with recurrent IHCA were less than half as likely to survive to discharge (12.7% vs 22.1%; adjusted OR: 0.46 [0.44-0.48], P.001) and have favorable neurological survival (7.0% vs 13.1%; adjusted OR: 0.44 [0.42-0.47], P.001). Compared with patients with recurrent OHCA, patients with recurrent IHCA also had lower rates of survival to discharge (12.7% vs 16.1%; adjusted OR: 0.81 [0.71-0.94], P = .005) and favorable neurological survival (7.0% vs 8.9%; adjusted OR: 0.66 [0.54-0.81], P.001). Despite worse survival outcomes, patients with recurrent IHCA were least likely to adopt DNAR orders within the first 24 hours after successful resuscitation compared with patients with no recurrent IHCA or recurrent OHCA (17.2% vs 18.9% and 26.6%, respectively) or withdraw care at any time (17.7% vs 24.4% and 31.2%, respectively).Nearly 1 in 8 patients with an IHCA has a recurrent IHCA, and these patients have worse outcomes than patients with only a single IHCA and those with an IHCA after being hospitalized for an OHCA. Despite worse survival, rates of DNAR and withdrawal of care were lowest for patients with recurrent IHCA. These findings provide important prognostic information for clinicians caring for patients with recurrent IHCA and suggest the need to better align resuscitation and end-of-life decisions with patients' prognoses after IHCA.

Article, see p 2454 The Serenity Prayer asks for the courage to change what can be changed, the serenity to accept what cannot be changed, and the wisdom to know the difference. Medicine demands large doses of all three. The greatest difficulty is deciding when the times call for more courage or more serenity. Some of our problems seem so intractable that we stop expecting progress during our professional lifetimes. Occasionally, however, advances completely unrelated to medicine give us cause to reconsider the comfort of our serenity-courage balance. Out-of-hospital cardiac arrest is one of medicine’s most vexing public health problems. Decades of research have failed to reveal any test that is sufficiently accurate to identify people who will have a sudden cardiac arrest (SCA) before the catastrophic event occurs. Huge research efforts have been expended to identify best resuscitation practices at the time of the SCA event (eg, how many inches of chest compression, at what rate, and with what ventilation strategy; airway management; and what adjuvant drug therapies) and best treatment practices in the hours and days following (including targeted temperature management and early coronary angiography). Community-wide emergency medical service (EMS) systems have been created to deliver interventions to SCA patients with a goal of arriving within 8 minutes of the 9-1-1 call at least 90% of the time. However, despite improvements in prehospital systems of care and bystander resuscitative efforts, absolute survival for out-of-hospital SCA has remained at or below 10%.1–3 Glimmers of the possibility of much higher survival rates have appeared in the form of observational reports of automatic external defibrillator (AED) use. The first AED was approved by the US Food and Drug Administration in 1998. Early work showed that when SCAs occurred in well-populated public spaces with an AED close at hand …

Background Black individuals have a disproportionately higher burden of heart failure with reduced ejection fraction (HFrEF) relative to other racial and ethnic populations. We conducted a systematic review to determine the representation, enrollment trends, and outcomes of black patients in historic and contemporary randomized clinical trials (RCTs) for HFrEF. Methods We searched PubMed and Embase for RCTs of patients with chronic HFrEF that evaluated therapies that significantly improved clinical outcomes. We extracted trial characteristics and compared them by trial type. Linear regression was used to assess trends in enrollment among HFrEF RCTs over time. Results A total of 25 RCTs, 19 for pharmacotherapies and 6 (n=9,501) for implantable cardioverter defibrillators, were included in this analysis. Among these studies, there were 78,816 patients, 4,640 black (5.9%), and the median black participation per trial was 162 patients. Black race was reported in the manuscript of 14 (56.0%) trials, and outcomes by race were available for 12 (48.0%) trials. Implantable cardiac defibrillator trials enrolled a greater percentage of black patients than pharmacotherapy trials (7.1% vs 5.7%). Overall, patient enrollment among the 25 RCTs increased over time (P = .075); however, the percentage of black patients has decreased (P = .001). Outcomes varied significantly between black and white patients in 6 studies. Conclusions Black patients are modestly represented among pivotal RCTs of individuals with HFrEF for both pharmacotherapies and implantable cardioverter defibrillators. The current trend for decreasing black representation in trials of HF therapeutics is concerning and must improve to ensure the generalizability for this vulnerable population.

Individual-level baseline covariate imbalance could happen more frequently in cluster randomized trials, and may influence the observed treatment effect. Using computer and real-data simulations, this paper quantifies the extent and impact of covariate imbalance on the estimated treatment effect for both continuous and binary outcomes, and relates it to the degree of imbalance for different numbers of clusters, cluster sizes, and covariate intraclass correlation coefficients. We focused on the impact of race as a covariate, given the emphasis of regulatory and funding bodies on understanding the influence of demographic characteristics on treatment effectiveness. We found that bias in the treatment effect is proportional to both the degree of baseline covariate imbalance and the covariate effect size. Larger numbers of clusters result in lower covariate imbalance, and increasing cluster size is less effective in reducing imbalance compared to increasing the number of clusters. Models adjusted for important baseline confounders are superior to unadjusted models for minimizing bias in both model-based simulations and an innovative simulation based on real clinical trial data. Higher outcome intraclass correlation coefficients did not affect bias but resulted in greater variance in treatment estimates.

BackgroundCluster-randomized trials (CRTs) are being increasingly used to test a range of interventions, including medical interventions commonly used in clinical practice. Policies created by the NIH and the Food and Drug Administration (FDA) require the reporting of demographics and the examination of demographic heterogeneity of treatment effect (HTE) for individually randomized trials. Little is known about how frequent demographics are reported and HTE analyses are conducted in CRTs.ObjectivesWe sought to understand the prevalence of HTE analyses and the statistical methods used to conduct them in CRTs focused on treating cardiovascular disease, cancer, and chronic lower respiratory diseases. Additionally, we also report on the proportion of CRTs that reported on baseline demographics of its populations and conducted demographic HTE analyses.Data sourcesWe searched PubMed and Embase for CRTs published between 1/1/2010 and 3/29/2016 that focused on treating the top 3 Center for Disease Control causes of death (cardiovascular disease, chronic lower respiratory disease, and cancer). Evidence Screening And Review: Of 1,682 unique titles, 117 abstracts were screened. After excluding 53 articles, we included 64 CRT publications and abstracted information on study characteristics and demographic information, statistical analysis, HTE analysis, and study quality.ResultsAge and sex were reported in greater than 95.3% of CRTs, while race and ethnicity were reported in only 20.3% of CRTs. HTE analyses were conducted in 28.1% (n = 18) of included CRTs and 77.8% (n = 12) were prespecified analyses. Four CRTs conducted a demographic subgroup analysis. Only 6/18 CRTs used interaction testing to determine whether HTE existed.ConclusionsBaseline demographic reporting was high for age and sex in CRTs, but was uncommon for race and ethnicity. HTE analyses were uncommon and was rare for demographic subgroups, which limits the ability to examine the extent of benefits or risks for treatments tested with CRT designs.

We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur.To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred.This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics.Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge.We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90;75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival.Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.